Abstract
Background:
The effects of non-infectious urinary catheter-related complications such as measurements of indwelling urinary catheter overuse, catheter-related trauma, and urinary retention are not well understood.
Methods:
This was a retrospective cohort study of 200 patients undergoing general surgery operations. Variables to measure urinary catheter use, trauma, and retention were developed, then surgical cases were abstracted. Inter- and intra-rater reliability were calculated for measure validation.
Results:
129 of 200 (65%) had an indwelling urinary catheter placed at the time of surgery. 32 patients (16%) had urinary retention, and variation was observed in the treatment of urinary retention. 12 patients (6%) had urinary trauma. Rater reliability was high (>90% agreement for all) for the dichotomous outcomes of urinary catheter use, urinary catheter-related trauma, and urinary retention.
Conclusions:
This study suggests a persistent high rate of catheter use, significant rates of urinary retention and trauma, and variation in the management of retention.
Keywords: Urinary Catheters, Urinary Retention, Postoperative Complications, Outcome Assessment, Health Care, urethral injury
Background
Surgical patients frequently have urinary catheters placed at the time of surgery for bladder decompression and/or measurement of urine output.(1) However, indwelling urinary catheter-related complications are some of the most common sources of iatrogenic harm.(2, 3) While catheter-associated urinary tract infection (CAUTI) has received much attention as a target for comparing and financially penalizing hospitals as a preventable event, recent studies have highlighted other harms, including a risk of urethral injury and lingering morbidity.(4–6) In a 2018 multicenter study of more than 2000 patients, patients were interviewed after a hospitalization during which a urinary catheter was used.(4) 11% of patients reported an infectious complication of their urinary catheter, while 55% of patients reported non-infectious morbidity, including urinary urgency, leakage, difficulty starting or stopping the urine stream, and pain with urination.(4) Thus, urinary catheters should be avoided when possible to minimize these complications.
While national efforts to reduce urinary catheter use in medical and surgical patients have reduced catheterization and CAUTI rates in hospitalized patients,(1, 7) there is evidence that urinary catheters continue to be overused in surgical settings.(8) A statewide study of cases in the Michigan Surgical Quality Collaborative (MSQC) registry from 2014–2015, demonstrated deviation from appropriateness criteria standards for indwelling catheter use in general surgery patients.(8) Furthermore, the study found significant variation by hospital quartile in duration of catheter use.(8) Additionally, in our work with the MSQC we have heard from surgeons that, while urinary catheter overuse and trauma are problems, the most common problem they see in their practices is the need for standardized protocols to diagnose and manage perioperative urinary retention. Surgeons have expressed interest in guidelines or pathways to guide the management of this common problem.
In this context, we set out to better understand the problems of urinary catheter overuse, urinary catheter trauma, and urinary retention in surgical patients. To measure these problems, we designed a set of variables for abstracting them from hospital electronic health records (EHRs). The specific aim of the present study is the development and validation of variables for measuring urinary catheter use, urinary catheter-related trauma, and urinary retention from EHRs in surgical patients. Ultimately, we hope to establish these new variables as quality measures for use in the MSQC for purposes of audit and feedback, as well as surveillance that will allow the effectiveness of future interventions to be tested that could improve rates of perioperative catheter use, catheter-related trauma, and urinary retention events.
Methods
Study Design and Cohort
This was a retrospective cohort study of patients from Michigan Medicine (also known as University of Michigan Health), a large academic medical center in Ann Arbor, MI. All patients who underwent selected surgical procedures between 1 May 2018 and 1 May 2020 were identified by search of surgery departmental billing records by CPT procedure codes. Procedure types included were appendectomy (CPT 44950, 44970), laparoscopic cholecystectomy (47562, 47563, 47564), abdominal colorectal surgery procedures (44120, 44125, 44140, 44141, 44143, 44144, 44150, 44160, 44187, 44188, 44202, 44204, 44205, 44206, 44210, 44227, 44310, 44320, 44620, 44625), pelvic colorectal surgery procedures (44145, 44146, 44155, 44158, 44207, 44208, 44211, 44212, 44626, 45110, 45111, 45113, 45119, 45395, 45397), groin hernia repairs (49505, 49507, 49520, 49521, 49525, 49550, 49553, 49555, 49557, 49650, 49651), ventral hernia repairs (49560, 49561, 49565, 49566, 49585, 49587, 49652, 49653, 49654, 49655, 49656, 49657), and anorectal procedures (0184T, 45171, 45172, 46250, 46255, 46257, 46258, 46260, 46261, 46262). The procedures were chosen because they represent common general surgery operations, and/or because of the availability of published Appropriateness Criteria for catheter use, and/or because prior research suggested possible catheter overuse. Colorectal procedures were oversampled because of literature and expert opinion regarding higher risk of retention in this group.
Cases were selected by procedure code using stratified random sampling without replacement and iterative rounds to augment the sample, so that our sample would contain 50% colorectal surgery cases and 10% from each of the other procedure groups. Urgent/emergency cases were excluded except in the case of appendectomy and cholecystectomy because many of these are categorized as urgent procedures, while still being routine. An Institutional Review Board application was submitted for this work, and it was deemed “Exempt” by IRBMED (application number HUM00184711).
Variable Design and Data Sources
The clinicians on the research team (JM, SH, CR) developed variables for EHR chart abstraction, with a goal of measuring perioperative urinary catheter use, duration of catheter use, urinary catheter-related trauma/injury, and urinary retention, including management, risk factors, and triggers for catheter use in cases of retention. Variable design was informed by the literature.(4, 9–15) It was also informed by our team’s and the MSQC’s experience with variable development and measure design/abstraction.(16–18) Our multidisciplinary team included experts from General Surgery, Urology, Nursing, and Internal Medicine, who have extensive experience studying urinary catheter use and complications.(4, 12, 19–21) We also solicited feedback from a Stakeholder Advisory Board, including practitioners in Nursing, Surgery, and Urology. Draft variables were then abstracted from pilot cases by the clinicians, and variables were edited for clarity. A detailed Abstraction Manual and flowchart were created, and regular meetings to discuss cases allowed for iterative improvements and clarifications to the Abstraction Manual and flowchart (Figure 1). Note that in Figure 1, some boxes include “yes” and “no” options. In these cases “yes” and “no” are the response options in the database, and the arrow to follow applies regardless of whether “yes” or “no” is chosen.
Figure 1:
Urinary Catheter Use, Postoperative Urinary Retention, and Urinary Catheter-Related Trauma Chart Abstraction Flowchart
Two research assistants were trained to perform chart abstractions, under the supervision of the clinicians, using a training format modeled on the experience of MSQC performing these types of abstractions.(16) CR, a clinician, was the third chart abstractor. The EHR in use in this institution is “MiChart”, designed by EPIC Systems Corporation, implemented in June of 2014.(22) Study data were collected and managed using Research Electronic Data Capture (REDCap) hosted at the University of Michigan.(23, 24) In addition to the chart abstractions, data were also obtained from the EHR-based data warehouse to add basic information such as demographics and comorbidities, thus decreasing data abstraction burden.
Chart Abstraction and Measure Validation
The hospital EHR was used to abstract indwelling urinary catheter use, trauma, and retention variables for 200 surgical cases. These data allowed for measurement of catheter use, catheter trauma, and urinary retention and its management in our cohort. Ten percent of charts were re-abstracted by the three data abstractors, so that intra-rater and inter-rater reliability could be measured for the following dichotomous outcomes (1) catheter use, (2) urinary retention, and (3) urinary trauma.
Statistical Analysis
Case characteristics, catheter use, and complications were summarized using descriptive statistics. Selected results were stratified by surgery type. Inter- and intra-rater reliability were measured by percent agreement and Gwet’s AC1 statistics.(25, 26) Stata/MP version 17.0 software for Mac (StataCorp, College Station, TX) was used for statistical analysis.
Results
Patient Characteristics
The cohort included 200 surgical patients, whose characteristics are summarized in Table 1. Surgical cases represented were 18 (9%) appendectomies, 19 (9.5%) cholecystectomies, 105 (53%) abdominal and pelvic colorectal operations, 38 (19%) hernia repairs, and 20 (10%) anorectal procedures. A total of 58 (29%) cases were outpatient surgery cases. In this cohort, only 7 (3.5%) of cases had preexisting risk factors for urinary retention, and 4 (2%) had urology consultations.
Table 1:
Patient Characteristics
| Characteristic | All patients (n=200) (% is of 200) |
Patients with retention (n=32)* (% is of 32) |
Patients with trauma (n=12)* (% is of 12) |
|---|---|---|---|
| Patient Characteristics | |||
| Age at admission (mean, median, IQR) | Mean = 53.5 (median 56, IQR = 39–66) | Mean = 56.0 (median 56.5, IQR = 42–69) | Mean = 53.8 (median 52, IQR = 38–67) |
| Sex (male) | 107 (53.5%) | 23 (71.9%) | 6 (50.0%) |
| Race (white) | 168 (84.0%) | 28 (87.5%) | 11 (91.7%) |
| ASA score 3 or 4 | 105 (52.5%) | 25 (78.1%) | 8 (66.7%) |
| Elixhauser comorbidity score** (mean, median, IQR) | Mean = 10.4 (median 4, IQR = 0–21) | Mean = 17.0 (median 16, IQR = 3–27) | Mean = 18.5 (median 16, IQR = 0–32) |
| morbidly obese (>=40) | 10 (10.0%) | 2 (6.25%) | 1 (8.3%) |
| Urology consultation during admission | 4 (2.0%) | 4 (12.5%) | 2 (16.7%) |
| Preexisting condition that increases risk for post-operative urinary retention | 7 (3.5%) | 7 (21.9%) | 1 (8.3%) |
| Hospitalization and Surgery Characteristics | |||
| Procedure Type | |||
| Appendectomy - lap | 18 (9.0%) | 1 (3.1%) | 1 (8.3%) |
| Cholecystectomy - lap | 19 (9.5%) | 0 (0%) | 0 (0%) |
| Abdominal colorectal -open and lap | 48 (24.0%) | 10 (31.3%) | 4 (33.3%) |
| Pelvic colorectal - open and lap | 57 (28.5%) | 19 (59.4%) | 4 (33.3%) |
| Inguinal/femoral hernia-open | 8 (4.0%) | 1 (3.1%) | 0 (0%) |
| Inguinal/femoral hernia- lap | 10 (5.0%) | 0 (0%) | 0 (0%) |
| Ventral/incisional hernia – open | 10 (5.0%) | 0 (0%) | 0 (0%) |
| Ventral/incisional hernia – lap | 10 (5.0%) | 1 (3.1%) | 1 (3.1%) |
| Anorectal procedures | 20 (10.0%) | 0 (0%) | 1 (3.1%) |
| Epidural | 16 (8.0%) | 4 (12.5%) | 0 (0%) |
| >= 3 liters (#, %) | 17 (8.5%) | 7 (21.9%) | 0 (0.0%) |
| > 3 hours | 66 (33.0%) | 22 (68.75%) | 5 (41.7%) |
| Outpatient surgery (#, %) | 58 (29.0%) | 1 (3.1%) | 2 (16.7%) |
| Patient went to ICU after surgery (within 30 d) (#, %) | 13 (6.5%) | 4 (12.5%) | 0 (0%) |
| Length of stay (mean, median, IQR) | Mean = 3.6 (median 3, IQR = 0 to 5) | Mean = 6.28 (median 5, IQR=3.5–6) | Mean = 3.08 (median 3, IQR=1.5–4.5) |
4 patients had both trauma and retention;
Elixhauser comorbidities scored according to AHRQ weighted algorithm; IQR = interquartile range; ASA = American Society of Anesthesiologists Physical Status Score; Lap = laparoscopic; MAP = Michigan Appropriate Perioperative Criteria(1); ICU = intensive care unit.
Urinary Catheter Use
Of the 200 surgical cases, 129 (65%) had an indwelling urinary catheter placed in the perioperative period. By procedure type, the proportion of cases with indwelling catheters for surgery were as follows: appendectomy 16 of 18 (89%); cholecystectomy 4 of 19 (21%); abdominal colorectal 42 of 48 (88%); pelvic colorectal 57 of 57 (100%); inguinal/femoral hernia 2 of 18 (11%); ventral hernia 8 of 20 (40%); and anorectal 0 of 20 (0%).
Catheter removal date was available in the EHR for 126 (98%) of catheterized patients. Of these patients, 31 (25%) had their catheters removed the same day as the surgery, 50 (40%) were removed post-op day 1, and 45 (36%) were removed post-op day 2 or later. Of the 31 patients with catheters removed on the same day as surgery, 24 (77%) were removed in the operating room, 2 (6%) were removed in the PACU, and 5 (16%) were removed after leaving PACU. The findings regarding urinary catheter duration by procedure type are summarized in Figure 2.
Figure 2:
Urinary Catheter Use and Duration by Procedure
Urinary Retention and Urinary Catheter Trauma
Thirty-two patients (16%) met criteria for urinary retention. Management of urinary retention among these patients is described in Table 2. These results show variation in the treatment of urinary retention, and in the bladder scanner volumes that trigger catheterization. Four (12.5%) patients with urinary retention were discharged still using a catheter.
Table 2:
Urinary Retention Management Among Patients with Retention (n=32)
| Treatment | # (%) of cases |
|---|---|
| Alpha-blocker medications | 9 (28.1%) |
| No volume documented | 8 (25%) |
| Urinary retention managed with ISC* only | 19 (59.4%) |
| Urinary retention managed with placement/replacement of foley catheter only | 6 (18.8%) |
| Urinary retention managed with ISC and placement/replacement of foley catheter | 4 (12.5%) |
| Bladder catheterization not required to manage retention | 3 (9.4%) |
| Patient discharged with plan for home ISC | 1 (3.1%) |
| Patient discharged with foley catheter | 3 (9.4%) |
ISC=Intermittent Straight Catheterization
Twelve patients (6%) met criteria for urinary catheter-related trauma. Most of the patients with urinary retention and trauma were patients undergoing pelvic and abdominal colorectal procedures. None of the patients undergoing cholecystectomy or anorectal procedures had urinary retention or catheter-related trauma. The frequency and rate of urinary retention and catheter trauma are summarized in Figure 3. There was no statistically-significant association between the duration of catheter use (in days) and the occurrence of trauma or urinary retention (data not shown).
Figure 3:
Urinary Retention and Catheter Trauma Frequency and Rate by Procedure
Figure 4 is a flowchart demonstrating the ultimate catheter use, trauma, and retention outcomes for the cohort, as well as inclusion and exclusion of cases for each outcome.
Figure 4:
Flowchart Demonstrating Catheter Use, Trauma, and Retention Outcomes for the Cohort, as well as Inclusion and Exclusion of Cases
Validation of Chart Abstraction
Ten percent of charts were randomly-selected and re-abstracted by each of the three abstractors, so that inter- and intra-rater reliability could be measured. The percent agreement between abstractors for the use of a urinary catheter was 90.5% (Gwet’s AC = 0.81). Percent agreement for urinary catheter-related trauma was 96.8% (Gwet’s AC = 0.97). There was perfect agreement among all three abstractors for urinary retention (Gwet’s AC = 1.00). Intra-rater reliability was similarly estimated by comparing the original chart abstraction results with re-abstraction results for each abstractor. The percent agreement for the use of a urinary catheter was 90.5% (Gwet’s AC = 0.81). There was perfect agreement for the presence of urinary catheter-related trauma and urinary retention (Gwet’s AC = 1.00). Taken together, these results demonstrate that reliability was high for all three dichotomous outcomes. While still showing strong reliability, our results indicate that identifying the use of urinary catheters in the EHR is subject to some degree of disagreement (<10%).
Discussion
The goal of this study was to develop and validate new measures for perioperative urinary catheter use, urinary retention, and urinary catheter-related trauma in surgical patients, because there are currently no published measures for these outcomes. We found that these measures can be abstracted from EHRs with high reliability. While the outcomes measured in this study have limited generalizability, they do begin to show us patterns of urinary catheter use and complications. We found that catheter use was infrequent for anorectal surgery, cholecystectomy, and groin hernia repairs, but frequent and variable in duration for appendectomy, ventral hernia repairs, and colorectal surgery. In our cohort, complications of urinary retention (16%) and trauma (6%) were measurable, and most frequent in the abdominal/pelvic colorectal surgery group.
This project was inspired by prior research suggesting urinary catheter overuse in surgical patients(8), as compared to best practices published in the 2019 Michigan Appropriate Perioperative (MAP) criteria.(1) We also were motivated in this work by recent studies demonstrating that harms other than CAUTI are likely significantly more common than CAUTI but are understudied.(3, 4) These findings raised the question of whether urinary catheter use and harms can be measured by hospital EHR chart abstraction. If so, process and outcomes measures could allow the effects of quality improvement interventions to be measured, and normative feedback to hospitals could be a component of quality improvement.
This project is part of a larger initiative to measure and reduce urinary catheter harms amongst surgical patients in Michigan. This work is in partnership with the MSQC, an organization in which trained nurses abstract data about surgical cases, care, and postoperative complications.(27) The first step toward implementing a new, meaningful quality improvement project is ensuring that the process or outcome targeted for improvement can be reliably measured.(28) This study provides a first step in validating the measurement of urinary catheter use in general surgery patients, as well as the outcomes of urinary catheter trauma, and urinary retention.
Prior to the start of this project, a survey of surgeons from the MSQC indicated that they considered urinary retention a significant problem in their practices. This study corroborates that sentiment, particularly when it comes to abdominal and pelvic colorectal surgery. The rate of retention in the cohort overall (16%) and amongst the abdominal/pelvic colorectal surgery cases (28%) is in agreement with other studies from the literature showing significant rates of postoperative urinary retention.(29) Our pilot study also measured how urinary retention was treated in the cases in which it occurred, and we observed wide variation in management strategies. A goal for future work is to use our developed measures of catheter use, urinary retention and urinary catheter-related trauma across the state of Michigan to scale up and assess the generalizability of our findings. While urinary catheter-related trauma is relatively rare, it has major consequences for affected patients. This preventable complication may also be a target for quality improvement interventions.
Why do urinary catheter overuse, trauma, and urinary retention warrant quality improvement efforts? Urinary catheter placement is one of the most common invasive procedure performed in the hospital setting. Because 55% of patients report pain and/or other symptoms after catheter use, patient-centered care mandates we minimize the use of these devices.(4) Furthermore, urinary retention prolongs hospital duration and thereby costs.(10) Finally, urethral injuries from catheters may require urology consultation or even surgery, and some cause permanent disability.(3)
Despite novel outcome measure development and sound data abstraction with high reliability, a few limitations should be discussed. First, although our inclusion criteria captured numerous types of surgical patients, findings from our single-site pilot study may not be generalizable to other tertiary care settings. Nevertheless, the validation of our measures will allow the relevant variables to be disseminated to other hospitals to allow for more generalizable measurement of these processes and outcomes. Furthermore, because the Epic EHR platform is widely used it is likely that many hospitals will have a similar experience with the variables, finding them feasible to abstract. Another limitation was the inability to know whether urinary catheters were used specifically because a suprapubic laparoscopic trocar/port was used. Stakeholders participating in developing the Michigan Appropriate Perioperative Criteria for urinary catheter use pointed out this indication for urinary catheter use for laparoscopic appendectomy, but our chart review showed that port-site locations are not consistently documented for laparoscopic procedures.(1)
From this study we learned several important lessions regarding the study of urinary catheter use and harms. First, we found that urinary catheter harms are not consistently captured in hospital billing data, making chart abstraction essential for accurate audit and feedback.(30) However, even clinician-supervised chart review confronts challenges. Lessons learned about the challenges of abstracting these measures included: (1) a consistent lack of catheter use and discontinuation information in physicians’ notes, requiring nursing notes and flowsheets to be the primary source of information; (2) automatic recording of urinary catheters in operating room supply lists, whether or not they were actually used; (3) urinary catheter information frequently missing from the “lines/drains/airway” section of the EHR; and (4) lack of inclusion of catheter morbidity in the discharge summary for the hospitalization.
Conclusions
This study demonstrates that urinary catheter use, urinary catheter-related trauma, and urinary retention are process/outcome measures that can be accurately abstracted from the EHR. Furthermore, this pilot study suggests a persistent high rate of catheter use, significant rates of urinary retention and trauma, and variation in the management of retention. These data suggest the potential for quality measurement and improvement.
Funding
This work was supported by the Agency for Healthcare Research and Quality (AHRQ) [grant number R01HS026912].
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